opportunities and limitations of cbt for psychosis: not a quasi … · 2020. 1. 19. · •cbtp...

Opportunities and limitations of CBT for psychosis: not a quasi-neuroleptic

Max Birchwood

„CBTp reduces (drug resistant)

psychotic symptoms, promotes

insight and increases medication

adherence‟

NICE, 2008

• Tim Beck

• Nick Tarrier

• Dave Kingdon and Doug T.

• Chadwick Birchwood Trower

• Garety Fowler. & Kuipers.

John Percival (1838)the first cognitive therapist in

psychosis

Percival, John. A Narrative of the Treatment Experienced by a

Gentleman, During a state of Mental Derangement; Designed to Explain

the Causes and Nature of Insanity, and to Expose the Injudicious

Conduct Pursued Towards Many Unfortunate Sufferers Under That Calamity.

2 vols. London: Effingham Wilson, 1838 and 1840.

(A mad people’s history of madness.

Dale Petersen, Ed. Pittsburgh, PA, University of

Pittsburgh Press, 1982)

What is CBTp?

• Verbal therapy to ease distress by reducing

positive symptoms

• Mobilises the client‟s capacity to reflect on and

to question delusional or self evaluative beliefs

• A „collaborative empirical‟ enterprise

Common ingredients

• Engagement , rapport and trust

• Shared formulation (why psychosis; why

now; why me?)

• Focus on delusional beliefs and

alternatives to delusional thinking

• Weighing evidence; antidote to „jumping to

conclusions‟

• Negative self-evaluative thinking

• Schema

• Relapse prevention

CBTp meta-analysis,Wykes et al 2007

Effect size= 0.73

Reason could be...

• CBTp works for some groups and certain

contexts (Not: FEP; in 12 months after

acute episode; relapse prevention )

• Is a complex intervention and key

ingredients camouflaged.

• Variation in CBTp model between

centres/trials

Could also be..

• PANSS is poor outcome for CBT:

symptoms not always synonymous with

distress or behaviour.

• CBTp a weak intervention for + symptoms

• Problems with the neuroleptic metaphor

Birchwood and Trower, 2006, The future of CBT for psychosis: not a quasi neuroleptic

British Journal of Psychiatry.

Primary outcome =

Severity of psychosis (PANSS)

Inclusion criterion =

Drug resistant symptoms

CBTp: a neuroleptic metaphor?

The neuroleptic metaphor

• PANSS is poor outcome for CBT:

1.symptoms not always synonymous with

distress or behaviour.

2. Can get 30% change in PANSS with no

change in psychosis

3. Can get change in PANSS+ but no

change in delusional conviction

• CBTp a weak intervention for + symptoms?

• Problem with the neuroleptic metaphor

Psychosis(PANSS)

Affect/Distress

Behaviour

Delusional

conviction

Unusual thought content

Person and context

Social Cognition: Emotional

Appraisal

Hallucinations

T1

T2

T3

± 7000

± 5600

± 4800

1 year

2 years

No depression

Depression

Distressing psychosis

4.0% 20.8%

Baseline delusional ideation/ depression

NEMESIS : Krabbendam et al, Br J Clin Psychology, 2003

• 80 children (mean 12 yrs) with „voices‟

recruited from community

• 60% voices discontinued after 3 yrs

• Continuation and distress predicted by:

emerging negative beliefs about voices

and development of depression

Psychosis(PANSS)

Affect/Distress

Behaviour

Delusional

conviction

Unusual thought content

Person and context

The interface of affect, threat

and delusional thinking

Persecutory thinking

Dimensions

of threat(Mis)interpretation

Affect

Intent ;powerThreat mitigation Event/hassle

Appeasement Safety behaviours

Identity/source

Interventions

• Change mis-interpretations (eg JTC )

• Affect, esp anxiety and worry:

• Dimensions of threat, esp. power vs. intent

Q: Can we change threat /distress without

changing delusional conviction?

Q: Can we change the „affectivity‟ of

psychotic experience without changing

content?

BELIEFS

[Power; intent]

EVIDENCESAFETY

BEHAVIOURS

AFFECT

Fear, guilt, elation,

depression

Voice

Activity

Omniscience:shame; predictions

Control

Threat Mitigation Appeasement

Appraisals, psychotic symptoms

and affect in daily life

Emmanuelle Peters, Inez Myin-Germeys,

Sally Williams, Kathryn Greenwood, Elizabeth

Kuipers, Jan Scott & Philippa Garety

Institute of Psychiatry,

U.K.

•10 random times a day

• 6 consecutive days

• provides ‘on-line’ measurement

Myin-Germeys et al, Arch Gen Psychiatry 2001

+

When the beep went off, I was thinking about?

This thought is… Not Medium High

1 2 3 4 5 6 71 2 3 4 5 6 71 2 3 4 5 6 7

1 2 3 4 5 6 7

PleasantClearNormal

I have trouble concentrating

I feel…CheerfullUnsecureLonely

RelaxedAnxiousSatisfied

IrritatedSadGuilty

My 1st complaint is presentMy 2nd complaint is present

My thoughts are…suspiciousdifficult to expressI can't get rid of theminfluenced by other

I feel unrealI hear voicesI see 'things'I fear to loose control

Where am I?

I'm alone? yes / no

If not, with whom?

How many men?………/ Women? ………/ Children? ………

I like this companyI prefer being aloneWe are acting together

What am I doing?

I prefer doing something elseI find myself activeIt consumes my energy

This activity is a challengeI'm skilled at it

I'm hungryI'm tiredI don't feel well

I LY DOWN / SIT / STAND / RUN / SPORT (Circle your choice)Since I woke up I used… (more choices possible)

O NOTHINGO ALCOHOL When was that?…… hours ………O MEDICATION When was that?…… hours ………O COFFEE O TABACCO O .............

Since I woke up the most important thing that happened was:

This was: veryunpleasant

-3 -2 -1 0 1 2 3verypleasant

This beep was disturbing

It is now exactly : ……… hours………minutes

Remarks:

---------------------- Do not write below this line ----------------------

WhereWhat1What2Who1Who2

EventDecoryEventWhatEventWhoMedic1Medic2Medic3

OnlineCathegoryGoofsThinkTimeThinkRelationThinkValue

DayNoBeepNo

Not Medium High

1 2 3 4 5 6 71 2 3 4 5 6 71 2 3 4 5 6 7

Not Medium High

1 2 3 4 5 6 71 2 3 4 5 6 71 2 3 4 5 6 7

Not Medium High

1 2 3 4 5 6 71 2 3 4 5 6 71 2 3 4 5 6 7

Not Medium High

1 2 3 4 5 6 71 2 3 4 5 6 7

Not Medium High

1 2 3 4 5 6 71 2 3 4 5 6 71 2 3 4 5 6 71 2 3 4 5 6 7

Not Medium High

1 2 3 4 5 6 71 2 3 4 5 6 71 2 3 4 5 6 71 2 3 4 5 6 7

Not Medium High

1 2 3 4 5 6 71 2 3 4 5 6 71 2 3 4 5 6 7

Not Medium High

1 2 3 4 5 6 71 2 3 4 5 6 71 2 3 4 5 6 7

Not Medium High

1 2 3 4 5 6 71 2 3 4 5 6 7

Not Medium High

1 2 3 4 5 6 71 2 3 4 5 6 71 2 3 4 5 6 7

Not Medium High

1 2 3 4 5 6 7

The Experience Sampling Method

Dependent variables(Multi-level linear regressions)

Voice intensity ratings

(range 2-7)

(ß)

Power appraisals (ß)

Control appraisals (ß)

1. Negative affect .07 .15* .05

2. Symptom distress

.38* .24* .05

Do voice appraisals predict

distress?

Appraisals about power, but not control or intensity of voices,

are related to negative affect;

power and intensity both related to symptom distress

* = p < .001

Power reflects the relationship hierarchy

EE infringements of relationship boundaries

The ‘expressed emotion’ of voices?

41%

3%

Variables selected t Sig.Beta

Voice Frequency (psyrat) .342 3.198 .002

Power X EE * .596 5.567 .000

42%

Cognitive therapy for command hallucinations

•Undermining the power of the voice, especially

its perceived ability to harm or shame

•Increasing the power of the voice hearer

•Affirming boundaries

Daily Mail front pageJune, 2007

CTCH:

The Theory in Brief

A Cognitive Model of Distress and

Behaviour within an Interpersonal

Relationship

The Compliance

Behaviour Cycle

B: Power Beliefs

Identity “The Voice is ………….. “ (%) Evidence …..

Control “I cannot control my voices…” (%) Evidence …..

Compliance “If I don‟t do what my voices say…”(%),

“If I don‟t listen to my voices…..” Evidence …..

Meaning & Purpose “My voices intention is to ……..” (%)

Evidence …..

B: Core Beliefs:

“I am …………” ”Others are ……….” (%) Evidence …..

Emotional

Consequences

Fear, Anxiety, Depression

A: Voice Activity

Safety BehaviorsAppeasementCompliance

Prevalence Rates

• Command hallucinations, occur at a high rate

in adult psychiatric patients (median 53%

across eight studies with a wide range from

18 to 89%) Shawyer et al (2003) Equivalent

prevalence rates in forensic populations

• 48% of CHs stipulate harmful or dangerous actions

• 33% comply with CHs

• 33% „appease‟ or show minor compliance, remain at risk of later compliance

Command to Kill

Others

(Treatment n = 6)

(Control n = 7)

‘cut her throat’

‘go and kill

someone’

‘kill the therapist’

‘kill your husband

and daughter’

Four patients in the

sample had attempted

to kill someone,

either by suffocation,

poisoning or physical

assault with a

hammer.

Three patients used

appeasement

behaviours including

arming themselves

with knives, baseball

bats and an axe and

making guns out of

tin foil.

CTCH Trail 1 Prevalence Example Compliance Appeasement

Commands to Kill Others

Command to Harm

Self

(Treatment n = 9)

(Control n = 3)

‘burn yourself’

‘cut yourself’

‘set yourself alight’

‘pour hot water on

yourself’

‘go into the road’

Nine patients had

harmed themselves in

response to

commands. This

included cutting,

swallowing nail

polish remover or

bleach, jumping in

front of cars, walking

on glass and setting

oneself alight

Three patients used

appeasement

behaviours including

picking at previous

wounds, and standing

on the kerb

Commands to Harm SelfCTCH Trail 1

Prevalence

Example Compliance Appeasement

CTCH From the Client‟s

View….

I‟m More Powerful Than my

Voice if I can……….

• Stop it

• Reduce it

• Start it

• Listen when I‟m ready

• Resist without penalty

There are Benefits if I Resist..

• I will not go to jail or hospital

• I will not upset others I care about or who

care about me

• I can hold my head high again

• I can get on with my life

Do my Powerful Voices…

• Always speak the truth?

• Predict the future accurately?

• Mean what they say – are they

unambiguous in their meaning?

Testing out the Power…

• I don‟t always appease and nothing

happens

• There are times when I don‟t comply and

nothing happens

• Can‟t harm the therapist or others that I

care about

Challenging the

Omnipotence of Voices:

A Trial of CT for Command

Hallucinations

The COMMAND trial

DESIGN

• Prospective , randomised ,single

blind, intention to treat RCT

• CT vs TAU

• Treatment over 6 months; 6 months

follow up

14%53%

% appeasing or complying at 12 months

TAU CTCH

Pre= 100% , both groups

Mean scores on the Voice Power Differential Scale

0

5

10

15

20

25

30

Baseline 6 month 12 month

28

17,4 18

2627.4

29,1

Mea

n s

core

Assessment

CTCH

TAUVoice more powerful

I am more powerful

Group X time :p<0.001

Mean Scores on Negative Content (PSYRATS)

0

1

2

3

4

Baseline 6 month 12 month

3,43,1

3,63,6 3,43,7

Mea

n S

core

Assessment

CTCH

TAU

0 = None

1 = Some

2 = Abusive re behaviour

3 = Abusive re self

4 = Extreme commands

“ The remarriage of emotion and psychosis”

• Cognitive model and treatment of

distress/behaviour not „psychosis‟

(PANSS secondary outcome)

• Interventions on the interface between

delusional thinking and emotion.

• CBT for ED and origins in „social defeat‟

The future of CBTp?

Fantasy futures (NICE, 2012)

• CBTp eliminates distress and (harmful) „acting on‟ voices and paranoid delusions, but „psychosis‟ can remain relatively unchanged

• CBTp reduces relapse by a) stress sensitivity + b) „roll-back‟ attenuated psychotic thinking... using real time ESM

• CBTp eliminates social anxiety, depression and suicidal thinking

• CBTp for ED in prodrome prevents psychosis


psychosis









John Percival wrote a lengthy account of his experience of

madness.

John Percival was one of twelve children of Spencer

Percival the only English prime minister to have been

assassinated….

When 27 he started seeing visions and hearing voices that

told him to do strange things. His behaviour became so

erratic that a 'lunatic doctor' was called who strapped him

to his bed and gave him broth and medicine.…

“Those voices commanded me to do, and made me believe a number of

false and terrible things.

I threw myself out of bed - I tried to twist my neck, - I struggled with my

keepers. When I came to Dr Fox's I threw myself over a style, absolutely

head over heels, wrestled with the keepers to get a violent fall, asked them

to strangle me, endeavoured to suffocate myself on my pillow, &c., threw

myself flat on my face down steep slopes

… and upon the gravel walk, called after people as my

mother, brothers, and sisters, and cried out a number of sentences,

usually in verse, as I heard them prompted to me - in short for a whole

year I scarcely uttered a syllable, or did a single act but from

inspiration”

The cognitive therapy

"On another occasion being desired to throw myself over a steep

precipice near the river Avon - with the promise that if I did so, I

should be in heavenly places, or immediately at home, I refused to do

so for fear of death, and retired from the edge of the precipice to

avoid temptation –

…but this last was not till after repeated experiments of other kinds

had proved to me that I might be deluded.

For I was cured at last, and only cured of each of these delusions

respecting throwing myself about, &c. &c., by the experience that the

promises and threats attendant upon each of them were false.

When I had fairly performed what I was commanded, and found that

I remained as I was, I desisted from trying it …

I knew I had been deceived - and when any voice came to order me to do

any thing, I conceived it my duty to wait and hear if that order was

explained, and followed by another - and indeed I often rejected the

voice altogether: and thus I became of a sudden, from a dangerous

lunatic, a mere imbecile, half-witted though wretched being: and this

was the first stage of my recovery."


psychosis









CBTpercival

opportunities and limitations of cbt for psychosis: not a quasi … · 2020. 1. 19. · •cbtp...

Documents